Dealing with risks in patient care

Quality management

Kai-Oliver Schramek

Kommissarischer Kaufmännischer Direktor

Hohbergweg 2
77933 Lahr/Schwarzwald

Phone: 07821 -925-2005
Mail: ed.nilcidem@kemarhcs.revilo-iak

Kathrin Heuing

Kaufmännische Direktorin

Hohbergweg 2
77933 Lahr/Schwarzwald

Phone: 07821 -925-2005
Mail: ed.nilcidem@gniueh.nirhtak

Sascha Rödder

Kaufmännischer Direktor

Hohbergweg 2
77933 Lahr/Schwarzwald

Phone: 07821 -925-2005
Mail: ed.nilcidem@reddeor.ahcsas

Klinikleitung, Qualitätsmanagement

Conference frequency: quartalsweise

Risk management

Hilberath Jan Niklas

Chefarzt der Klinik für Anästhesiologie und Intensivmedizin

Phone: 07821 -925-2001
Fax: 07821-925-392110
Mail: ed.nilcidem@htareblih.naj

Anästhesiologie und Intensivmedizin Qualitätsmanagement Leitung OP, Zentralsterilisation, HKL, Röntgen

Conference frequency: quartalsweise

Risk management instruments and measures

No. Explanation
RM01

Comprehensive quality and/or risk management documentation (QM/RM documentation) is available

Qualitätsmanagementhandbuch (17.04.2023)

RM02

Regular further education and training measures

RM04

Clinical emergency management

Qualitätsmanagementhandbuch (17.04.2023)

RM05

Pain management

Qualitätsmanagementhandbuch (17.04.2023)

RM06

Fall prophylaxis

Qualitätsmanagementhandbuch (17.04.2023)

RM07

Use of a standardised concept for pressure ulcer prophylaxis (e.g. “Expert Standard for Pressure Ulcer Prophylaxis in Nursing”)

Qualitätsmanagementhandbuch (17.04.2023)

RM08

Regulated handling of custodial measures

Qualitätsmanagementhandbuch (17.04.2023)

RM09

Regulated handling of occurring malfunctions of devices

Qualitätsmanagementhandbuch (17.04.2023)

RM10

Structured implementation of interdisciplinary case discussions/conferences

Case review conference

  • Mortalitäts- und Morbiditätskonferenzen
RM12

Use of standardised information sheets

RM13

Application of standardised surgical check lists

RM14

Preoperative summary of predictable critical surgical steps, surgical time and expected blood loss

Qualitätsmanagementhandbuch (17.04.2023)

RM15

Preoperative, complete presentation of necessary findings

Qualitätsmanagementhandbuch (17.04.2023)

RM16

Procedure to avoid procedural and patient mix-ups

Qualitätsmanagementhandbuch (17.04.2023)

RM17

Standards for recovery and postoperative care

Qualitätsmanagementhandbuch (17.04.2023)

RM18

Discharge management

Qualitätsmanagementhandbuch (17.04.2023)

Fault reporting systems

Conference committee

Conference frequency: quartalsweise

Measures

u.a.: Checkliste Patientensicherheit, Informationsblätter für Patienten zu Sturz-, Schmerz- und Dekubitusprävention, Reanimationsteam, Regelmäßige Hygieneschulungen zur Vermeidung nosokomialer Infektionen, M&M-Konferenzen

No. Explanation
IF01

Documentation and procedural instructions for handling the error reporting system are available

As of: 29.01.2021

IF02

Internal evaluation of the received reports

taken quartalsweise

IF03

Training of employees in handling the error reporting system and in implementing the findings from the error reporting system

taken jährlich

Conference committee

Conference frequency: